ATI RN
RN Mental Health Bipolar Disorder ATI Questions
Question 1 of 9
A nurse is assessing a 49-year-old homeless male client. The nurse fashions the assessment process based on the understanding that the client would most likely demonstrate which of the following?
Correct Answer: D
Rationale: The correct answer is D. Homeless individuals often display resistance and caution due to past negative experiences or mistrust of authority figures. This behavior is a defense mechanism to protect themselves. A nurse should approach with empathy, patience, and non-judgmental attitude to build trust gradually. Choices A, B, and C are incorrect as they assume the client will be cooperative, talkative, or willing to engage in discussions, which may not be the case for a homeless individual who may have faced trauma or discrimination. It is essential for the nurse to acknowledge the client's feelings and validate their concerns before proceeding with the assessment.
Question 2 of 9
A client with depression is prescribed fluoxetine. On a return visit to the clinic, the client tells the nurse that he also just started taking St. John's wort to feel better. The nurse assesses the client for which of the following?
Correct Answer: C
Rationale: The correct answer is C: Serotonin syndrome. This is because both fluoxetine and St. John's wort increase serotonin levels in the brain, leading to a risk of serotonin syndrome - a potentially life-threatening condition characterized by symptoms such as confusion, agitation, sweating, and muscle twitching. Water intoxication (A) is not typically associated with these medications. Increased depressive symptoms (B) may occur if the client stops taking fluoxetine abruptly, but not specifically due to the combination with St. John's wort. Hypertensive crisis (D) is not a common concern with these medications.
Question 3 of 9
A patient diagnosed with major depressive disorder has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken antidepressant medication for 1 week. Which nursing intervention has the highest priority?
Correct Answer: A
Rationale: The correct answer is A: Implement suicide precautions. This is the highest priority intervention because the patient has a plan for suicide, which poses an immediate risk to their safety. Implementing suicide precautions involves ensuring the patient's safety by removing any potential means of self-harm, closely monitoring their behavior, and providing constant supervision to prevent any suicide attempts. Choice B is incorrect because offering high-calorie snacks and fluids frequently does not address the immediate risk of suicide. Choice C is incorrect because assisting the patient to identify personal strengths is important for building self-esteem but is not the highest priority when the patient is at risk of suicide. Choice D is incorrect because observing the patient for therapeutic effects of antidepressant medication is important but ensuring the patient's safety takes precedence when there is a risk of suicide.
Question 4 of 9
The nurse is reviewing the medical records of several patients diagnosed with major depression. The nurse identifies which patient as least likely to commit suicide?
Correct Answer: D
Rationale: The correct answer is D, the married man. Research shows that individuals who are married have a lower suicide risk compared to those who are single, divorced, or widowed. Marriage provides social support, stability, and a sense of belonging which can act as protective factors against suicide. Divorced individuals (choice A) and widowed individuals (choice B) may experience loneliness and grief which can increase their suicide risk. Single individuals (choice C) may lack the support system that marriage provides, making them more vulnerable to suicide. Therefore, the married man is least likely to commit suicide due to the protective factors associated with being in a marital relationship.
Question 5 of 9
A client is receiving methadone maintenance therapy. After teaching the client about this treatment, the nurse determines that the teaching was successful when the client states which of the following?
Correct Answer: B
Rationale: The correct answer is B: "I should eat small frequent meals if I get nauseated." This is correct because methadone can cause nausea as a side effect, and eating small, frequent meals can help alleviate this symptom. Option A is incorrect because alcohol should be avoided while on methadone therapy. Option C is incorrect as methadone should be taken with food to reduce gastrointestinal side effects. Option D is incorrect as constipation, not diarrhea, is a common side effect of methadone therapy.
Question 6 of 9
An adult client has described a personal loss. Before touching the client to offer comfort, what should the nurse consider?
Correct Answer: B
Rationale: The correct answer is B: the client's cultural background. Before touching the client to offer comfort, the nurse should consider the client's cultural background to ensure that the gesture is appropriate and respectful. Different cultures have varying attitudes towards touch, and what may be comforting in one culture could be inappropriate or invasive in another. Understanding the client's cultural background helps the nurse provide culturally sensitive care. Incorrect choices: A: the client's recent vital signs - Vital signs are important for assessing physical health, but they are not directly relevant to offering comfort through touch in this situation. C: if the doctor should be notified - Notifying the doctor is not necessary before offering comfort through touch. It is more important to consider the client's needs and preferences. D: if the client has been sad recently - While the client's emotional state is important, it is not the primary consideration before offering comfort through touch. Cultural background plays a more crucial role in determining the appropriateness of touch.
Question 7 of 9
A nurse is caring for four clients. Which of the following clients should the nurse care for first?
Correct Answer: D
Rationale: The correct answer is D because the client requiring a sterile dressing change for a burn has the highest priority due to the risk of infection and potential complications. Sterile technique is crucial to prevent infections in burn wounds. Burn injuries can lead to sepsis if not properly managed. Clients receiving chemotherapy (Choice A) may require careful monitoring but do not have an immediate risk of infection like the burn client. A client who has had an appendectomy and has diminished bowel sounds (Choice B) may indicate a potential complication but is not as urgent as managing a burn wound. A client with hypothyroidism and stupor (Choice C) may require intervention but does not pose an immediate threat to life like a burn wound needing a sterile dressing change.
Question 8 of 9
Which chronic medical condition is a common trigger for major depressive disorder?
Correct Answer: C
Rationale: The correct answer is C: Hypothyroidism. Hypothyroidism is a common trigger for major depressive disorder due to its impact on hormone levels, particularly thyroid hormones that regulate mood. When thyroid levels are imbalanced, it can lead to symptoms of depression. Pain (choice A), hypertension (choice B), and Crohn's disease (choice D) can also contribute to depression but are not as directly linked to triggering major depressive disorder compared to hypothyroidism.
Question 9 of 9
A patient fearfully runs from chair to chair crying, "They're coming! They're coming!" The patient does not follow the staff's directions or respond to verbal interventions. The initial nursing intervention of highest priority is to
Correct Answer: A
Rationale: The correct answer is A: provide for the patient's safety. This is the highest priority because the patient is exhibiting behaviors that indicate distress and potential harm to themselves or others. Ensuring the patient's safety is the immediate concern to prevent any accidents or dangerous situations. Choice B is incorrect because encouraging clarification of feelings is not the priority when the patient is in a state of distress and potential danger. Choice C is incorrect as respecting personal space is important but not the most critical in this urgent situation. Choice D is also incorrect as offering an outlet for energy is not the immediate need when the patient is displaying alarming behaviors.